Association of the coronavirus disease 2019 (COVID-19) pandemic with the incidence of healthcare-associated infections in California hospitals.

OBJECTIVE: To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on the incidence of central-line-associated bloodstream infections (CLABSIs), Clostridioides difficile infections (CDIs), and methicillin-resistant Staphyloccocus aureus (MRSA) bloodstream infections (BSIs) in California acute-care hospitals. DESIGN: Retrospective cohort and before-and-after study. METHODS: We compared standardized infection ratios (SIRs) for CLABSI, CDI, and MRSA BSI from the second half of 2020 to the second half of 2019. We performed interrupted time-series (ITS) analyses for these infections to assess departures from long-term trends. We also examined the association between the proportion of facility beds that were occupied by COVID-19 patients in May and June of 2020 and the incidence of infections using negative binomial models. In addition, we compared standardized antimicrobial administration ratios (SAARs) for the second halves of 2019 and 2020. RESULTS: We detected substantial and significant increases in the SIRs for CLABSI and MRSA BSI from 2019 to 2020. For the ITS analysis, CLABSI and had significant positive values for the pandemic onset level-change parameters, and CLABSI and MRSA BSI had significant positive values for the postinterruption slope-change parameters. We also detected a positive association between facility COVID-19 patient occupancy and CLABSI and MRSA BSI incidence. We did not detect associations with the onset of the pandemic or COVID-19 patient occupancy and CDI. The SAAR for all antibacterial drugs decreased slightly, but the SAAR for drugs with a high risk for CDI increased slightly. CONCLUSIONS: This study adds to a body of literature documenting increases in CLABSI and MRSA BSI incidence during the pandemic.

Healthcare-associated infection reporting completeness and quality during the coronavirus disease 2019 (COVID-19) pandemic in California hospitals.

We examined markers of completeness in healthcare-associated infection (HAI) data reported by California hospitals to the National Healthcare Safety Network for each half of 2020 compared with 2019. There were indications of decreased data completeness for both halves of 2020. California 2020 HAI data should be interpreted with caution.

Descriptive Epidemiology of Infant Botulism in California: The First 40 Years.

OBJECTIVE: To ascertain the descriptive epidemiology of infant botulism, the flaccid paralysis that results when neurotoxigenic Clostridium species produce botulinum toxin (BoNT) in the infant colon, in its first 40 years following initial recognition in California in 1976. STUDY DESIGN: Cases were defined by laboratory identification of BoNT and/or neurotoxigenic Clostridium species in patients' feces. Parents were interviewed using a structured questionnaire. Descriptive epidemiologic characteristics were compared between 1976-1996 and 1997-2016. RESULTS: From 1976-2016, 1345 cases of infant botulism occurred in 45 of 58 California counties (6.5 cases/100 000 live-births/year) caused by BoNT types A, B, Ba, Bf, and F; 88% of cases were ≤6 months of age and 51% were female. Cases were white (84.2%), Asian (8.9%), other races (3.8%), and African American (2.8%); 29.4% of cases were Hispanic. More than 99% of cases were hospitalized. Case occurrence peaked in summer-fall. Of 8 designated geographic regions, the Central Coast counties had 3 times the statewide incidence in both 20-year time periods. Breast-fed patients (83%) were more than twice as old at onset as formula-fed patients (median, 4.4 vs 1.7 months, respectively; P < .001). BoNT/A cases were older at onset than BoNT/B cases (median, 3.8 vs 2.9 months, respectively; P < .001). CONCLUSIONS: Comprehensive continuous surveillance of infant botulism for 40 years in a large, diversely populated state identified fundamental epidemiologic characteristics of this uncommon illness. Unusual features included greater than 99% case hospitalization, absence of male preponderance, and a distinctive age distribution.

Seven-Year Case-Control Study in California of Risk Factors for Infant Botulism.

OBJECTIVE: To ascertain possible risk factors for infant botulism, the intestinal infectious form of human botulism, in the years immediately following its initial recognition in California in 1976. STUDY DESIGN: Parents of 159 California laboratory-confirmed cases of infant botulism from 1976 to 1983 and 318 healthy controls were interviewed using a comprehensive (>300 factors) questionnaire. "Neighborhood controls" (n = 184) were matched on date of birth, sex, race/ethnicity, and neighborhood of residence. "County controls" (n = 134) were matched only on date of birth, sex, and county of residence. Age-stratified bivariate and multivariate conditional logistic regression analyses were performed using SAS. RESULTS: All cases required hospitalization. Bivariate analyses identified several risk factors that in multivariate analyses were not significant. In multivariate analyses, risk factors differed with stratification by age. For the ≤2 month-old neighborhood controls comparison, birth order >1, cesarean delivery, ≤1 bowel movements (BMs) per day, and windy residence area were associated with illness hospitalization, and for the county controls comparison, only pacifier use was associated. For the <2 month-old neighborhood controls comparison, <1 bowel movements (BMs) per day, cesarean delivery, birth order >1, and windy residence area were associated with illness hospitalization, and for the county controls comparison, pets in the home was an additional risk factor. CONCLUSIONS: With the exception of the ≤2-month-old county controls group, slower intestinal transit time (≤1 BM/d) was associated with illness. Otherwise, our case-control investigation identified few physiologic, environmental, and maternal factors associated with infant botulism hospitalization in California.

Variable Case Detection and Many Unreported Cases of Surgical-Site Infection Following Colon Surgery and Abdominal Hysterectomy in a Statewide Validation.

OBJECTIVE To assess hospital surgical-site infection (SSI) identification and reporting following colon surgery and abdominal hysterectomy via a statewide external validation METHODS Infection preventionists (IPs) from the California Department of Public Health (CDPH) performed on-site SSI validation for surgical procedures performed in hospitals that voluntarily participated. Validation involved chart review of SSI cases previously reported by hospitals plus review of patient records flagged for review by claims codes suggestive of SSI. We assessed the sensitivity of traditional surveillance and the added benefit of claims-based surveillance. We also evaluated the positive predictive value of claims-based surveillance (ie, workload efficiency). RESULTS Upon validation review, CDPH IPs identified 239 SSIs following colon surgery at 42 hospitals and 76 SSIs following abdominal hysterectomy at 34 hospitals. For colon surgery, traditional surveillance had a sensitivity of 50% (47% for deep incisional or organ/space [DI/OS] SSI), compared to 84% (88% for DI/OS SSI) for claims-based surveillance. For abdominal hysterectomy, traditional surveillance had a sensitivity of 68% (67% for DI/OS SSI) compared to 74% (78% for DI/OS SSI) for claims-based surveillance. Claims-based surveillance was also efficient, with 1 SSI identified for every 2 patients flagged for review who had undergone abdominal hysterectomy and for every 2.6 patients flagged for review who had undergone colon surgery. Overall, CDPH identified previously unreported SSIs in 74% of validation hospitals performing colon surgery and 35% of validation hospitals performing abdominal hysterectomy. CONCLUSIONS Claims-based surveillance is a standardized approach that hospitals can use to augment traditional surveillance methods and health departments can use for external validation. Infect Control Hosp Epidemiol 2017;38:1091-1097.

Substantial variation in hospital rankings after adjusting for hospital-level predictors of publicly-reported hospital-associated Clostridium difficile infection rates.

Across 366 California hospitals, we identified hospital-level characteristics predicting increased hospital-associated Clostridium difficile infection (HA-CDI) rates including more licensed beds, teaching and long-term acute care (LTAC) hospitals, and polymerase chain reaction testing. Adjustment for these characteristics impacted rankings in 24% of teaching hospitals, 13% of community hospitals, and 11% of LTAC hospitals.

Ancillary benefits of prenatal maternal serum screening achieved in the California program.

OBJECTIVE: To evaluate the extent of fetal structural abnormalities, other than neural tube and abdominal wall defects (AWDs), identified by California's Prenatal Screening Program. METHODS: The Quad Marker Prenatal Screening records of 516,172 women were examined for screening interpretation and the diagnosis of structural abnormalities detected via follow-up. Women who were screen-positive for trisomy 21, trisomy 18, neural tube defects (NTDs) or Smith-Lemli-Opitz syndrome (SLOS) received follow-up services at state-approved Prenatal Diagnosis Centers (PDCs). Detailed reports of services and diagnostic information were linked in a database to the original screening results. RESULTS: A total of 26 323 women received follow-up ultrasound services at the PDCs in the study time period. Of these women, 1085 (4.1%) were identified as having fetuses with significant structural abnormalities, other than NTDs (n = 207) or AWDs (n = 254). In addition to the structural abnormalities, 225 cases of fetal demise, 4 molar pregnancies, 15 cases of twin-to-twin transfusion, and 92 cases with placental abnormalities were identified. CONCLUSION: While Prenatal Screening Programs do not explicitly screen for structural abnormalities other than NTDs and AWDs, clearly many other structural abnormalities may be associated with a screen-positive status. Thus, the detection of these additional structural defects can be considered an ancillary program benefit.

Non-firearm-related homicide, New Mexico, 2001-3.

OBJECTIVE: New Mexico (NM) has the highest rate of non-firearm-related homicide in the USA and ranks 20th in firearm-related homicides. Because non-firearm-related homicides are inadequately described in the literature, characterisation of non-firearm-related homicide victims will enhance efforts to reduce homicides. METHODS: Homicide victims were identified through the Office of the Medical Investigator. Age-specific and age-adjusted homicide death rates were calculated for 2001-3 by sex and race/ethnicity, and associations between covariates and non-firearm-related homicide were measured. RESULTS: Non-firearm-related homicides comprised 33% of US homicide victims, 47% of NM homicide victims, and 74% of NM American Indian (AI) homicide victims. Of 212 NM non-firearm-related homicide victims, 37% had been beaten, 32% had been stabbed, and 12% had been strangled. Females comprised 30% of non-firearm-related homicide victims and 18% of firearm-related homicide victims. A blood alcohol concentration (BAC) >or=0.08 mg/dl was detected among 43% of non-firearm-related (61% of AI) and 33% of firearm-related (50% of AI) homicide victims. Non-firearm-related homicide rates were highest among AI men aged 25-34 years (31/100,000). Non-firearm-related homicide victims were more likely than firearm-related victims to be AI (adjusted odds ratio (AOR) 4.20; 95% CI 2.16 to 8.16) and female (AOR 2.05; 95% CI 1.27 to 3.31), and to have had a BAC >or=0.08 mg/dl (AOR 1.65; 95% CI 1.08 to 2.52). CONCLUSIONS: Homicide-prevention efforts among AIs in NM should focus on non-firearm-related homicides. The association between excessive drinking and non-firearm-related homicide should be further characterised. Continued surveillance for non-firearm-related homicides will assist these efforts.

Triple-marker prenatal screening program for chromosomal defects.

OBJECTIVE: To examine screening performance of California's triple-marker screening program, using data from a statewide registry for chromosomal defects. METHODS: This study included 752,686 women who received a screening risk and had an expected date of delivery between July 2005 and the end of June 2007. Follow-up diagnostic services for screen-positive women were performed at state-approved centers. Data on diagnostic outcomes from these visits were entered into the California Chromosomal Defect Registry (CCDR). Other CCDR sources include mandatory reporting by all cytogenetic laboratories and hospitals and outcome data forms submitted by prenatal care providers. RESULTS: The observed detection rate for Down syndrome (N=1,217) was 77.4%. It varied significantly by gestational dating method and maternal age. The rates for women aged younger than 35 years and 35 years and older were 62.4% and 94.0%, respectively. The detection rates were 81.3% for ultrasound-dated pregnancies and 67.5% for last menstrual period-dated pregnancies. For Turner syndrome, trisomy 18, triploidy, and trisomy 13, the detection rates were 79.4%, 82.5%, 98.1%, and 36.0%, respectively. The positive rate for Down syndrome was 5.4%. Of women with a Down syndrome fetus who were screen positive, only 49.5% opted for amniocentesis. Of women who obtained results from amniocentesis indicating a Down syndrome fetus, 61.4% had an elective termination, 26.2% had a live birth, 4.5% had a death or miscarriage, and 7.9% had an unknown outcome. CONCLUSION: The observed performance of this large triple-marker screening program exceeds generally predicted detection rates for Down syndrome. This study methodology will be used to measure the performance of subsequent screening enhancements. LEVEL OF EVIDENCE: III.

Prevalence of viral respiratory tract infections in children with asthma.

BACKGROUND: Previous studies support a strong association between viral respiratory tract infections and asthma exacerbations. The effect of newly discovered viruses on asthma control is less well defined. OBJECTIVE: We sought to determine the contribution of respiratory viruses to asthma exacerbations in children with a panel of PCR assays for common and newly discovered respiratory viruses. METHODS: Respiratory specimens from children aged 2 to 17 years with asthma exacerbations (case patients, n = 65) and with well-controlled asthma (control subjects, n = 77), frequency matched by age and season of enrollment, were tested for rhinoviruses, enteroviruses, respiratory syncytial virus, human metapneumovirus, coronaviruses 229E and OC43, parainfluenza viruses 1 to 3, influenza viruses, adenoviruses, and human bocavirus. RESULTS: Infection with respiratory viruses was associated with asthma exacerbations (63.1% in case patients vs 23.4% in control subjects; odds ratio, 5.6; 95% CI, 2.7- 11.6). Rhinovirus was by far the most prevalent virus (60% among case patients vs 18.2% among control subjects) and the only virus significantly associated with exacerbations (odds ratio, 6.8; 95% CI, 3.2-14.5). However, in children without clinically manifested viral respiratory tract illness, the prevalence of rhinovirus infection was similar in case patients (29.2%) versus control subjects (23.4%, P > .05). Other viruses detected included human metapneumovirus (4.6% in patients with acute asthma vs 2.6% in control subjects), enteroviruses (4.6% vs 0%), coronavirus 229E (0% vs 1.3%), and respiratory syncytial virus (1.5% vs 0%). CONCLUSION: Symptomatic rhinovirus infections are an important contributor to asthma exacerbations in children. CLINICAL IMPLICATIONS: These results support the need for therapies effective against rhinovirus as a means to decrease asthma exacerbations.

Analysis of 200 food items for benzo[a]pyrene and estimation of its intake in an epidemiologic study.

Animal studies have shown that dietary intake of benzo[a]pyrene (BaP), a polycyclic aromatic hydrocarbon (PAH), causes increased levels of tumors at several sites, particularly in the upper gastrointestinal tract. However, the role of dietary intake of BaP and cancer in humans is not clear. We created a BaP database of selected food products that could be linked to Food Frequency Questionnaires (FFQs) to estimate BaP intake. BaP levels were measured for each food line-item (composite samples) which consisted of a variety of foods in a FFQ. Composite sample parts were derived from the Second National Health and Nutrition Examination Survey (NHANES II) which represents the most common food items consumed by the general population. Meat samples were cooked by different techniques in controlled conditions, and by various restaurants and fast-food chains. Non-meat products were purchased from the major national supermarket chains. The quantities of BaP were measured using a thin-layer chromatography (TLC)/spectrofluorometer technique and were highly correlated with both BaP (r=0.99) [corrected] and sum of carcinogenic PAH (r=0.98) measured by HPLC technique. We linked our database to the results from a FFQ and estimated the daily BaP intake of various food items in 228 subjects in the Washington, DC metropolitan area. The highest levels of BaP (up to about 4 ng BaP/g of cooked meat) were found in grilled/barbecued very well done steaks and hamburgers and in grilled/barbecued well done chicken with skin. BaP concentrations were lower in meats that were grilled/barbecued to medium done and in all broiled or pan-fried meat samples regardless of doneness level. The BaP levels in non-meat items were generally low. However, certain cereals and greens (e.g. kale, collard greens) had levels up to 0.5 ng/g. In our population, the bread/cereal/grain, and grilled/barbecued meat, respectively, contributed 29 and 21 percent to the mean daily intake of BaP. This database may be helpful in initial attempts to assess dietary BaP exposures in studies of cancer etiology.

Mortality among workers exposed to cutting oil mist: update of previous reports.

BACKGROUND: Earlier reports of the mortality experience of this cohort of automotive workers followed from 1938 to 1967 who were exposed to cutting oil mist noted an excess of gastrointestinal cancer. The present report describes the mortality experience of these workers followed for mortality through 1980. METHODS: Cause-specific standardized mortality ratios were calculated by comparing the observed number of deaths to the expected numbers based on rates for the U.S. male population. RESULTS: The SMRs for liver and biliary tract, and testicular cancers were significantly elevated. Among the subset of workers with heavy oil mist exposure, SMRs were significantly elevated for cancers of the lung and testis, and for Hodgkin's disease. The risk of death due to lung cancer was greatest among workers with heavy exposure to oil mist employed for 15 or more years. Mortality due to stomach cancer was in excess among workers with heavy exposure to oil mist who were employed for 5 or more years. There were significant excesses of deaths due to asthma and emphysema. CONCLUSIONS: Further studies with information on the presence of contaminants and additives in oil mists will help elucidate the relationship between oil mist exposure and cancer.

Cancer mortality and environmental exposure to DDE in the United States.

To explore the role of DDE, the major and most persistent DDT derivative, in cancer etiology, we examined the association of the 1968 adipose DDE levels of population samples from 22 U.S. states with age-adjusted mortality rates between 1975 and 1994 for multiple myeloma; non-Hodgkin lymphoma (NHL); and cancer of the breast, corpus uteri, liver, and pancreas. Separate analyses were conducted by gender and race. Covariates in the regression models included average per-capita income, percent metropolitan residents, and the population density. Liver cancer mortality increased significantly with adipose DDE levels in both sexes among whites, but not among African Americans. No association was observed for pancreatic cancer and multiple myeloma. Breast cancer mortality was inversely correlated with adipose DDE levels among both white and African American women. Significant inverse correlations were also observed for uterine cancer among white women, whereas no association was observed for African Americans and for NHL among whites (men and women) and African American women. The results for pancreatic cancer, multiple myeloma, NHL, breast cancer, and uterine cancer did not support the hypothesis of an association with past adipose levels of the DDT derivative DDE. The multivariate analysis confirmed most findings. The association between liver cancer and DDE observed among whites, particularly in view of the occurrence of hepatic neoplasms in laboratory animals exposed to DDT, warrants further investigation.

Cancer risk in the rubber industry: a review of the recent epidemiological evidence.

OBJECTIVES: To examine the recent epidemiological evidence on cancer risk among workers in the rubber industry. METHODS: Epidemiological studies published after the last detailed review by the International Agency for Research on Cancer (IARC) in 1982 were reviewed. 12 cohort studies in nine countries that examined distinct populations of workers in the rubber industry, seven industry based nested case-control studies, 48 community based case-control studies in 16 countries, and 23 studies based on administrative data that reported risks for employment in the rubber industry were identified. RESULTS: Excess risks of bladder cancer, lung cancer, and leukaemia were found in most studies, with risks above 1.5 in about half of the studies. A moderate excess risk for laryngeal cancer was consistent across studies. Excess risks were found in a few studies for cancers of the oesophagus, stomach, colon, liver, pancreas, skin, prostate, kidney, brain, and thyroid, and for malignant lymphoma and multiple myeloma, but overall results were not consistent for these neoplasms. CONCLUSIONS: Magnitude of the observed risks varied considerably between studies, but overall the findings indicate the presence of a widespread moderate increased cancer risk among rubber workers. The most consistent results were for bladder, laryngeal, and lung cancer and for leukaemia. Excess risks were also found for other neoplasms but an evaluation of the consistency of the findings is difficult because of the possible selective reporting of results. Recent studies do not provide information associating specific exposures with cancer risk. The preventive measures taken in the rubber industry in recent years may decrease risks, but this has not been documented yet in epidemiological studies.

Reactive chemicals and cancer.

Epidemiologic evidence on the relation between reactive chemicals and cancer is reviewed. These highly reactive chemicals (acrylonitrile; bis[chloromethyl]ether and chloromethyl methyl ether; 1,3-butadiene, ethylene oxide; formaldehyde; mustard gas; sulfuric acid; and vinyl chloride) vary in use and exposure. All are animal carcinogens that also have received considerable epidemiologic attention. Acrylonitrile is a chemical of current economic importance. The epidemiologic evidence is quite weak, but the available studies were very small. Epidemiologic studies clearly demonstrate that bis (chloromethyl) ether and chloromethyl methyl ether cause lung cancer. Continued follow-up of exposed workers is encouraged to provide information on risks for other cancers. Results from epidemiologic studies of butadiene-exposed workers are somewhat inconsistent, but the largest study with the best exposure assessment found the largest relative risk for leukemia. The failure of several larger studies to replicate the early Swedish findings of a very strong association between leukemia and ethylene oxide has not been adequately explained. Epidemiologic studies of formaldehyde provide limited evidence for an association with cancer of the nasopharynx and possibly with nasal cancer. These very rare tumors, however, are difficult to study epidemiologically. Mustard gas is a well-established lung carcinogen, but a recent follow-up of the English cohort suggests that other sites also may be affected. Sulfuric acid appears to cause laryngeal cancer. A suggested relationship with lung cancer in a few studies is of concern because of the widespread opportunity for exposure from ambient air pollution. Vinyl chloride causes angiosarcoma of the liver, but a large, multi-country study provided no clear evidence that other sites are affected.